Evaluation and Management of Periorbital Soft Tissue Trauma

Systemic Stabilization

The evaluation and treatment of periorbital injuries begin after the patient has been stabilized and life-threatening injuries addressed. A complete and thorough assessment is required to ensure that life- and limb-threatening injuries have been adequately assessed and managed before the periorbital area is addressed.

Medical History

A complete history is obtained, with an emphasis on the time course and circumstances of the injury. In children and the elderly, consideration must be given to the possibility of nonaccidental trauma. A history consistent with injuries from high-speed projectile particles typically requires the appropriate imaging studies to determine the presence of intraocular or intraorbital foreign bodies. Animal and human bites deserve particular attention and are managed accordingly with the administration of appropriate antibiotics.

Examination

Once the patient is medically stable, a comprehensive ophthalmic and adnexal assessment is required. We advocate a methodical and stepwise approach to this examination. The periorbital region is first assessed, beginning with the skin envelope. Attention is directed to the presence, location, and depth of skin and subcutaneous injury. Particular emphasis is placed on a thorough examination of the eyelid margin and the medial and canthal regions because lacerations in these areas can be difficult to identify immediately. Injuries to the skin and soft tissue must be carefully documented and their dimensions recorded. Photography is often helpful for documentation in these situations. Lacerations of the eyelid margin should be carefully examined for the presence of full-thickness margin-involving lacerations. The medial canthal area must be examined for the presence of injuries to the lacrimal system and medial canthal tendon because such injuries can have long-lasting sequelae. Lateralization of the punctum is a sign that a canalicular laceration and/or damage to the medial canthal tendon is likely. Similarly, poor apposition of the eyelid to the globe medially also suggests damage to the medial canthal tendon. If an injury to the lacrimal system is suspected, lacrimal probing with or without irrigation can be performed. In many cases, a knowledge of medial canthal anatomy makes probing and irrigation unnecessary. For example, if there is a full-thickness laceration medial to the punctum and the eyelid is lateralized, the likelihood of canalicular injury is extremely high. The integrity of the lateral canthal tendon must also be assessed and the tendon repaired if indicated.

In analyzing the extent of soft tissue injury to the eyelids, it is helpful to conceptualize the eyelid in terms of anterior, middle, and posterior lamella. The anterior lamella is composed of the skin and orbicularis. The middle lamella is composed of the tarsus, lower-eyelid retractions, Müller’s muscle, levator muscle, and septum. The palpebral conjunctiva constitutes the posterior lamella. Immediately recognizing the lamellae involved can aid the surgeon in identifying the particular anatomical structures that must be addressed. In addition, reconstructive maneuvers often treat these lamellae as functional subunits in the eyelid.

A detailed understanding of neurovascular anatomy is also required, and care must be directed to injuries that may involve branches of the facial nerve and critical periorbital vasculature.

Following assessment of the skin envelope and adnexa, the periorbital bony anatomy is assessed. This can be accomplished by carefully and methodically palpating the lateral, superior, and inferior orbital rims. The nasal sidewall is also assessed for step-offs and deformities. A low threshold for obtaining radiographic studies should be maintained because bony orbital trauma may not be immediately obvious.

The cranial nerves are examined sequentially, with particular focus on the frontal and zygomatic branches of the facial nerve and cranial nerves III, IV, and VI. It is important to assess sensation in the territories of the first and second divisions of the fifth cranial nerve. Attention is then directed toward the ophthalmic portion of the examination.

The ophthalmic examination should proceed in a similar methodical, stepwise fashion. Visual acuity, pupil examination, intraocular pressure testing, extraocular motility, and confrontation visual field testing are the cornerstones of a complete ophthalmic examination and should be performed in every patient where possible. Next, a complete ophthalmic examination is performed. We find it helpful to proceed methodically from anterior to posterior. The conjunctiva and sclera are examined first, with an emphasis on detecting lacerations. Examiners should be aware that large amounts of subconjunctival hemorrhage may obscure a scleral laceration, and if indications exist, a low threshold should be maintained for operative globe exploration. The cornea is examined next. Fluorescein staining is a useful adjunct, both for the detection of abrasions and for exploring Seidel positivity. The anterior chamber is examined next, with care taken to ascertain depth as well as the presence of foreign material, cell and flare, and synechiae. The lens is examined next. A sectoral cataract or dislocation may indicate penetrating injury. A full dilated examination is then performed to examine the vitreous and retina.

In situations where globe injury is suspected, a shield is placed over the eye in question without pressure on the eye. It is important to perform a full and comprehensive examination of the fellow eye.

Ancillary Testing

In most emergency department settings, basic laboratory studies typically have been performed. If the injury is chronic and purulent, a culture is warranted to guide antibiotic therapy. In many scenarios, radiographic testing, typically computed tomography (CT), is indicated as the test of choice. There should be a low threshold to obtain a CT scan because bony trauma in the orbit can often go undetected. Additionally, imaging is often very helpful in the event that retained foreign material is present in the soft tissue or the globe itself. Caution must be used if magnetic resonance imaging (MRI) is planned because there may be retained metallic foreign material.

Documentation

All injuries are documented precisely and completely with a detailed description in the patient’s charts. Photographic documentation is advised in all cases. Bullets and other projectiles must be retained and marked so that no break occurs in the chain of evidence. The medicolegal implications can be significant, so every effort must be made to complete the preoperative documentation of every injury.

Infection Prophylaxis

Depending on the mechanism of injury, preventing infection is of the utmost concern. Although the role of antibiotic prophylaxis has been controversial, we advocate thoughtful use of appropriate antibiotic prophylaxis. In the case of obviously contaminated wounds with extensive injury, a thorough washout should be performed, with a low threshold for the use of systemic antibiotic prophylaxis. Less extensive injuries and superficial abrasions may not require systemic antibiotics, but topical antibiotic ointment should be used. The patient should be queried regarding their tetanus immunization history and provided a tetanus vaccine if the patient is not up to date or is unaware of their last vaccination ( Table 12.9.1 ). In the case of an animal bite, all information about the animal’s history, the owner of the animal, and the site of injury must be recorded and the local animal care department notified. In these situations, the standard rabies protocol must also be followed.

The role of antibiotic prophylaxis in cases of animal bites has been controversial. Cat bites carry a high risk for infection, mainly with Pasteurella multocida . The mechanism of injury, typically a deep puncture wound, increases the risk of contamination and subsequent infection. Infection prophylaxis should be initiated with either amoxicillin/clavulanate or penicillin VK 500 mg a day for 5–7 days. In penicillin-allergic patients, tetracycline can be used as an alternative. A more detailed discussion on dog bites can be found later, but these injuries also carry a risk of infection. A thorough washout is required, and antibiotic prophylaxis should be strongly considered in all wounds that are surgically closed and in high-risk injuries. Amoxicillin/clavulanate is the antibiotic of choice.

Human bite injuries also carry a high risk for infection because of the large number of bacteria present. As a result, it is necessary to provide appropriate broad-spectrum antibiotic coverage, such as penicillin, amoxicillin/clavulanic acid, cephalexin, or ciprofloxacin.

Almost universally after a traumatic injury, it is prudent to copiously irrigate all injured tissue with antibiotic irrigation solution. Any remaining foreign material should also be removed to prevent future infection.

Timing of Repair

The timing of surgical repair is dependent on many factors. Ideally, all injuries would be repaired almost immediately following the initial injury. First and foremost, the patient must be systemically evaluated for any signs of more life-threatening injuries. Once the patient has been cleared and thoroughly examined, every effort should be made to arrange for prompt surgical repair. The timing for anesthesia may also be dependent on the patient’s last intake of food. Depending on the nature of the patient’s injuries, there may be multiple specialists involved, which also takes coordination and may result in a delay. The best chance for successful restoration of function and cosmesis exists in the first surgery, so it is in both the surgeon and the patient’s best interest to arrange for the personnel needed.

In some cases, the patient has more pressing systemic issues that have to be addressed first. In these circumstances, waiting 24–48 hours does not typically negatively affect the patient, but it is recommended to initiate an antibiotic regimen to prevent secondary infection of the open wound. The wound should also be kept moist with saline-soaked gauze and topical ophthalmic lubrication to prevent exposure keratopathy.